Mainplace Post Acute

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate for one of four sampled residents (Resident 1). * The facility failed to ensure Resident 1's physician's progress notes were accurate and did not contain information of other residents. * The facility failed to ensure Resident 1's skin assessments were documented by the licensed staff. These failures had the potential for the resident's care needs not to be met as their medical information was inaccurate and incomplete.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure two of three final sampled residents (Residents 4 and 9) reviewed for accident hazards were free from accident hazards. * Resident 4 had a witnessed fall incident on 10/18/25, resulting in a left hip fracture and hospitalization. The facility failed to ensure appropriate safety measures were implemented during Resident 4's use of the sit-to-stand lift machine, including ensuring proper staff positioning and use of the sling's waist belt. Furthermore, the facility failed to conduct a thorough investigation to determine the cause of Resident 4's fall incident. * The facility failed to implement the use of a floor mattress (floor mat) as a fall risk precaution as ordered by the physician for Resident 9. [...]

Inspectors wroteBased on interview and facility document review, the facility failed to ensure one out of one CNA (CNA 7) demonstrated the competencies and skill sets needed to provide safe nursing care. * The facility failed to ensure CNA 7 had the appropriate competence and skill set required to safely operate the sit-to-stand lift machine. In addition, CNA 7 was unable to differentiate between the types of belts used with the lift and was unable to identify the appropriate sling size for the sit-to-stand lift machine. This failure resulted in Resident 4 experiencing a fall on 10/18/25, from the sit-to-stand lift machine, sustaining a left hip fracture requiring hospitalization for surgery and symptoms of depression following the incident; and had the potential to put the residents at risks for the care not provided in a safe and competent manner.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to provide the necessary dialysis care and services for three of five final sampled residents (Residents 1, 63, and 135) reviewed for dialysis. * The facility failed to monitor Residents 1 and 63's fluid intake accurately as per the physician's order. In addition, the facility failed to monitor Resident 1 and 63's dialysis access site accurately. * The facility failed to ensure Resident 135's dialysis access site was consistently and accurately assessed as ordered by the physician. These failures had the potential for the residents not being provided with the appropriate care and services, and the possibility of medical complications related to the dialysis access site and fluid overload.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility had a medication error rate of 12% when three medication errors occurred out of 25 opportunities during the medication administration for one of one final sampled resident (Resident 51) and two nonsampled residents (Residents 72 and 156) reviewed for medication administration. * Resident 51 was almost given an outdated zinc sulfate capsule (used for wound healing). * Resident 72's apixaban (blood thinner, used to reduce the risk of blood clot) was not administered during the medication administration because the medication was not available. * Resident 156 dorzolamide ophthalmic solution (used to reduce high pressure inside the eye) was not administered because it was not available. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the two microwaves utilized to warm up the food was in a sanitary condition. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the ice machine utilized for residents and staff was maintained in a sanitary condition. * The facility failed to ensure the kitchen equipment was air dried prior to storage. * The facility failed to ensure the expired juice was discarded. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program from January 2025 through February 2026. The facility conducted surveillance of the resident infections only when the residents were prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and symptoms of infection and were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria). The facility failed to include these residents in the facility's infection control surveillance program. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure the grievances presented to the facility were thoroughly investigated for two of two nonsampled residents (Residents 54 and 165) reviewed for grievances. * The facility failed to clarify and address Resident 54's grievance about the facility's inventory process. * The facility failed to address and thoroughly investigate the grievance for Resident 165 when the resident was transported to the wrong appointment location. These failures had the potential for the residents to cause the residents to feel hopeless and may negatively affect their emotional well-being and overall care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure a copy of the advance directive was obtained and maintained in the medical record and the POLST was complete for three of twelve final sampled residents (Residents 5, 130, and 135) reviewed for advance directives and POLSTs. * The facility failed to ensure Resident 5's advance directive was in her medical record. * The facility failed to ensure Resident 130's POLST was completely filled out. * The facility failed to ensure Resident 135's POLST was completely filled out. These failures had the potential for the residents' wishes related to the provision of the medical treatment and services to not be followed if the residents were unable to make medical decisions for themselves.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain a clean, sanitary, and homelike environment for five residents' room (Rooms A, B, C, D, and E) of the facility. * Room A window was missing four vertical blinds.* Room B window had two broken blind slats.* Room C window had one broken blind slat.* Room D window was missing one blind slat, and the restroom faucet sink was leaking.* Room E wall paint below the overhead light was peeling off and the restroom baseboard behind the toilet and below the sink was coming off. These had the potential for the residents to be at risk for living in an unkempt environment.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 4 and 163) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure the nonpharmacological interventions were implemented prior to the use of trazodone HCl (hydrochloride) (antidepressant) medication for Resident 4. * The facility failed to monitor the orthostatic hypotension for Resident 163 related to the use of risperidone (Risperdal, antipsychotic medication). These failures had the potential for the residents to experience potential harm from the adverse consequences from the use of the psychotropic medications.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility did not report an allegation of verbal abuse to the CDPH, L&C Program, Ombudsman Office, and local law enforcement agency for two of four nonsampled residents (Resident 54 and 154) reviewed. * Resident 54 reported during resident's council meeting on 2/11/26, about allegation of verbal abuse against CNA 4. * Resident 154 reported during resident's council meeting on 2/11/26, about allegation of verbal abuse against CNA 4. This failure had the potential for Residents 54 and 154 to be vulnerable to further abuse and emotional distress.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to investigate an allegation of abuse for two of four nonsampled residents (Residents 54 and 154). * Resident 54 reported during the resident's council meeting on 2/11/26, about allegation of verbal abuse against CNA 4. * Resident 154 reported during resident's council meeting on 2/11/26 about allegation of verbal abuse against C.NA 4. This failure had the potential for Residents 54 and 154 to be vulnerable to further abuse and emotional distress.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was developed and implemented for two of 30 final sampled residents (Residents 1 and 7). * The facility failed to develop a care plan to address Resident 1's non-compliance with his prescribed fluid restriction. * The facility failed to implement a care plan intervention to provide an APP mattress for Resident 17, who was at risk for the development of pressure injuries. These failures placed the residents at risk of not being provided appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the risk and development of pressure injuries for two of two final sampled residents (Residents 17 and 147) reviewed for pressure injuries. * Resident 17 was at risk for the development of pressure injuries. The facility failed to ensure Resident 17's physician's order dated 2/28/26, for an APP mattress for skin maintenance/prevention was implemented. * The facility failed to reposition Resident 147 at least every shift which potentially led to the development of his pressure injury after admission on 8/2025. These failures placed the residents at risk for the development or worsening of pressure injuries.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services for the use of the enteral feedings for one of one final sampled resident (Resident 147) reviewed for enteral feedings. * The facility failed to ensure the enteral water flush for Resident 147 was accurately programmed per the physician's order. In addition, the facility failed to change Resident 147's water bag and enteral feeding tubing after 24 hours of use. These failures posed the risk for developing dehydration complications and potential infections for Resident 147.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for four of four final sampled residents (Residents 10, 45, 102 and 163) reviewed for respiratory services. * The facility failed to discard Resident 10's nasal cannula tubing dated 1/22/26. In addition, the facility failed to ensure the set-up bag for the nasal cannula for Resident 10 was dated. * The facility failed to ensure a physician's order was obtained when oxygen was administered to Resident 45. * Resident 102's nebulizer mask and tubing was not dated and changed once a week. * The facility failed to ensure the nebulizer mask was dated and labeled, and stored in a set-up bag for Resident 163. These failures had the potential for these residents not to receive appropriate respiratory care, and for increased risks of infection.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure appropriate pain management for one of one final sampled resident (Resident 4) reviewed for pain management. * The facility failed to ensure the nonpharmacological interventions were provided to Resident 4 prior to the administration of hydrocodone hydrocholoride (HCl) (pain medication). This failure had the potential to put the resident at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the pharmacy consultant's recommendations were acted upon for one of 30 final sampled residents (Resident 1) reviewed for drug regimen review. * The facility failed to follow-up the pharmacy consultant's recommendation to add a warning to the medication sheet regarding the handling of finasteride (medication used to treat benign prostatic hyperplasia or enlarged prostate) for Resident 1. This failure had the potential to put the licensed nurses at risk for adverse consequences related to the medication.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 156) observed for the medication administration was free from significant medication errors. * The facility failed to ensure Resident 156 received Dorzolamide Ophthalmic Solution 2% (used to reduce high pressure inside the eye) as ordered when Resident 156 did not receive at least three doses of dorzolamide eye solution. This failure had the potential to have a negative impact on the resident resulting in poor eye pressure control and long-term vision loss.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure proper medication storage for two of six medication/treatment carts inspected (Medication Cart A and Treatment Cart B). * The facility failed to ensure an outdated insulin, unlabeled insulin, and opened undated insulin pens were removed from Medication Cart A. * The facility failed to ensure a partially used sterile wound dressing was removed from Treatment Cart B. These failures had the potential for unsafe medication administration/wound treatment and to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure food brought to the facility from outside sources for the resident consumption was properly labeled, dated, and stored one of 30 final sampled residents (Resident 108). * Resident 108's food was unlabeled, undated, and not properly stored. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consume food brought from outside sources.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in one of four garbage dumpsters of the facility. * One garbage dumpster was observed with the lid partially propped open by garbage bags and boxes. This failure had the potential to attract pest/rodents that carried diseases.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the informed consent was completed prior to the use of a psychotropic medication for one of five final sampled residents (Resident 80) reviewed for informed consent. * The facility failed to ensure Resident 80's informed consent included the date and signature of the physician under the prescriber's section of the form. This failure had the potential to violate the residents' rights of not being fully informed of the medications and treatments.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure one of five nonsampled residents (Resident 154) during the Resident Council Meeting was informed of how to contact the State Survey Agency and to communicate with them when needed. This failure had the potential to negatively impact the residents' rights to be informed.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was developed to reflect the individual care needs for one of six sampled residents (Resident 1). * There was no care plan developed for Resident 1's refusals to shower or bathe. This failure had the potential for the resident to not be provided with appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of six sampled residents (Resident 1). * The facility failed to ensure a change in condition assessment and monitoring was completed for Resident 1's rash on the bilateral hands. This failure posed the risk of the resident to not receive appropriate care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 1) was free from the significant medication errors. * The facility failed to administer Resident 1's Cortef (generic name: hydrocortisone, a corticosteroid) as ordered by Resident 1's neurosurgeon. This failure posed the risk for Resident 1 to have an increased pain, swelling, fatigue, weakness, and nausea.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of three sampled residents (Resident 2) maintained their rights to manage the financial affairs. * The facility failed to ensure Resident 2 was involved in the decision-making process for his financial affairs and failed to inform Resident 2 that his personal funds (social security money) was directly deposited into the RFMS account. These failures resulted in Resident 2 losing control of his social security benefit money to the facility and further risk for Resident 2's finances to be lost, misused, and not easily accessible.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record was complete and accurately documented for one of three sampled residents (Resident 3). * Resident 3's MAR failed to show the lung sounds were documented. * There were no documented interventions after Resident 3's blood pressure reading of 91/49 mmHg. * There was no documentation of Resident 3's meal percentages. * There was no documentation Resident 3 was monitored for signs and symptoms of a urinary tract infection. * There was no documentation Resident 3 was being monitored for side effects of Bumex (diuretic). These failures had the potential for the resident's care needs to not be met as their medical information was not complete and accurate.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure five of five final sampled residents (Residents 27, 55, 98, 101, and 440) reviewed for respiratory care were provided with the appropriate respiratory care when: * The facility failed to ensure Resident 440's physician's order for the use of CPAP machine was clarified to the physician. In addition, the facility failed to provide proper maintenance for the CPAP machine use at bedside. * The facility failed to follow the physician's order for the administration of continuous oxygen and failed to ensure the nasal cannula was stored in a sanitary manner for Resident 55. * The facility failed to clarify the physician's order for the oxygen administration when the order for the use of oxygen did not specify the amount of oxygen to be administered for Resident 55. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review the facility failed to ensure the residents were free from the unnecessary psychotropic medications for four of five final sampled residents (Residents 45, 75, 85, and 101) reviewed for the unnecessary medications. * The facility failed to ensure the PRN order for the antipsychotic (medications used to treat symptoms of psychosis) medication was limited to 14 days for Resident 45. * The facility failed to ensure the non-pharmacological interventions were implemented prior to the administration of psychotropic medications for Resident 85. * The facility failed to ensure the nonpharmacological interventions were implemented prior to the administration of psychotropic medications for Resident 101. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food was served at a temperature to ensure palatability for one of 30 final sampled residents (Resident 60) and two nonsampled residents (Residents 62 and 131). This deficient practice had the potential to impact the residents' nutritional status and not meet the residents' desires to be served food they felt was palatable and attractive.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the proper labeling and dating of food in the refrigerator. * The facility failed to ensure the kitchen utensils had smooth cleanable surfaces and were in good repair. * The facility failed to ensure the kitchen utensils were stored and kept in sanitary conditions and free of food particle or residue. * The facility failed to ensure the blender and metal pans were air-dried prior to storing. These failures had the potential for cross contamination and cause foodborne illnesses in a medically vulnerable population who consumes food prepared in the facility's kitchen.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to inform the physician of the residents prescribed antibiotics with signs and symptoms not meeting McGeer's Criteria (criteria used by long-term care facilities to determine a true infection) for five of 30 final sampled residents (Residents 60, 75, 101, 110, and 840) and 24 nonsampled residents (Residents 16, 21, 24, 48, 50, 63, 96, 100, 117, 120, 123, 740, 741, 742, 743, 745, 746, 747, 748, 749, 750, 751, and 752). This failure had the potential risk for continued use of unnecessary antibiotics, potentially resulting in adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 30 final sampled residents (Residents 11 and 98) were assessed to determine if it was safe for them to self-administer their medications prior to self-administering their medications. * Resident 98 had a tube of Preparation H (topical medication used for hemorrhoids) and a tube of mometasone furoate (topical corticosteroid medication used for certain skin conditions) at the bedside. Resident 98 did not have a physician's order for self-administration of medications at the bedside. * A bottle of Lumify eye drops (medication to temorarily relieve eye redness and itching) and a bottle of Systane eye drops (medication to temporarily relieve dry, irritated eyes) were kept at Resident 11's bedside table. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed the conduct the status post change of condition assessments for one of three closed records reviewed (Resident 138). * Resident 138 had a change of condition involving an episode of vomiting, abdominal discomfort, and refusing to eat. The facility failed to follow up with the physician regarding the change of condition in a timely manner, failed to monitor Resident 138's vital signs, and failed to conduct and assessment related to the resident's change in condition. These failures had the potential for Resident 138's changes in medical condition not being identified, potentially delaying necessary care and treatment.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure injuries and promote the healing of existing pressure injuries for one of three final sampled residents (Resident 840) reviewed for pressure injuries. * The facility failed to provide Resident 840 with the LAL mattress as ordered by the physician. Additionally, the facility failed to ensure Resident 840's pressure injuries were assessed weekly in accordance with the facility's policy and the resident's plan of care. These failures had to potential for Resident 840 to not receive the appropriate care and services to promote healing or prevent the development and worsening of pressure injuries.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four final sampled residents (Resident 91) reviewed for falls was free from accident hazards. * The facility failed to place the floor mats on both sides of Resident 91's bed as ordered by the physician and resident's care plan for Resident 91. This failure had the potential for serious injury to the resident.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure appropriate pain management for two of two final sampled residents (Residents 85 and 98) reviewed for pain management. * The facility failed to administer pain medication according to the physician's order for Resident 98. * The facility failed to ensure Resident 85 was consistently provided non-pharmacological interventions for pain prior to the administration of narcotic pain medication. These failures put Residents 85 and 98 at risk for ineffective pain management.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the Pharmacy Consultant failed to recognize the irregularity for one of five sampled residents (Resident 75) reviewed for unnecessary medications when Resident 75 who was a diabetic and on Insulin (an injectable medication used to lower blood sugar) did not have any HbA1C level checked for 10 months. This failure placed Resident 75 at an increased risk for developing preventable dangerous effects from uncontrolled high blood sugar.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were not stored at the bedside for one nonsampled resident (Resident 107). In addition, the facility failed to ensure the proper disposal of treatment supplies for one of five medication/treatment carts (Treatment Cart 1)inspected for medication storage and labeling. *The facility failed to ensure one tube of CalaZinc (ointment used to treat and prevent skin irritation and diaper rash, and to protect minor cuts, burns, and dry, cracked skin), one spray bottle of Sea-Clens (saline-based solution for cleansing acute and chronic wounds), and one tube of Critic-Aid (ointment that helps prevent and treat most skin irritation due to incontinence) were not stored in 107's bedside drawer. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to maintain the safe infection control practices to help prevent the development and transmission of diseases and infection. * The licensed nurse (LVN 1) failed to use the appropriate sanitizing wipes when disinfecting the blood pressure machine. This failure had the potential for cross contamination (spread of germs and bacteria) and infection.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the pneumococcal vaccine was administered to one of five residents (Resident 31) reviewed for immunizations. This had the potential to put Resident 31 at risk of contracting pneumococcal disease.

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment for one nonsampled resident (Resident 102). * Resident 102 resided in Room A. Room A was observed with scratches and chipped pain on the wall adjacent to Resident 102's bed. This failure had the potential to negatively impact the resident's quality of life.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the comprehensive care plan for one of 30 final sampled residents (Resident 55). * Resident 55's care plan for the use of continuous oxygen therapy showed to administer oxygen at a rate of two liters per minute; however, the nursing staff failed to implement the care plan as evidenced by having administered continuous oxygen therapy to Resident 55 at a rate of four liters per minute. This failure posed the risk for not providing appropriate an individualized care to the resident.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage was properly stored and covered in one of four garbage dumpsters. This failure had the potential to attracts pest/rodents that carried diseases.

Inspectors wroteBased on interview, the facility failed to provide sufficient space for communal dining for three of eight residents (two final sampled residents, Residents 27 and 60; and one nonsampled resident, Resident 63) interviewed during the resident council meeting. * The residents stated the facility failed to provide a communal dining area for the residents in the facility who did not require staff assistance with meals. The residents stated only the residents who required staff assistance with meals had access to the communal dining area. This failure had the potential to inhibit socialization and negatively affect the residents' quality of life.

Inspectors wroteBased on interview and medical record review, the facility failed to develop a plan of care to reflect the individual care needs for two of two sampled residents (Resident 2 and 3). * The facility failed to develop a care plan problem to address Resident 2's breast cancer and use of Femara (hormone based chemotherapy medication to treat breast cancer) medication. In addition,the facility failed to ensure a care plan problem addressing Resident 2's limited physical mobility included a measurable timeframe for the goal. * The facility failed to ensure a care plan problem addressing Resident 3's limited physical mobility included a measurable timeframe for the goal. These failures posed the risk of not providing appropriate, consistent, and individualized care to Residents 2 and 3.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was informed in advance of their proposed treatments or treatment options to choose the preferrable option for the change in services. * The facility failed to ensure Resident 1 was informed and given the right to choose his treatment services when the facility changed his outpatient psychiatry services to inhouse psychiatry services. This failure had the potential to prevent the resident from participating in his treatment decisions.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the laboratory services for one of three sampled residents (Resident 1). * The facility failed to carry out the physician's order for laboratory testing for Resident 1. * The facility failed to ensure the abnormal laboratory test results for Resident 1 were reported to the physicianin a timely manner. Thesefailures had the potential to adversely affect the resident's physical health and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement their P&P regarding the AMA discharge for one of two sampled residents (Resident 1). * The facility failed to provide the appropriate instructions including to contact the physician immediately when Resident 1 was AMA discharged as per the facility's P&P. In addition, the physician was not informed of the resident wanting to leave AMA until after the resident had left the facility. These failures had the potential to place Resident 1 at risk for medical complications post-discharge.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was provided quality care when LVN 3 failed to administer Resident 1's Lasix (diuretic) as ordered and did not inform the physician. This failure had the potential to cause harm and delayed medical treatment for Resident 1.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of existing pressure injuries for two of two sampled residents (Residents 2 and 3). * The facility failed to ensure Resident 2's wound treatments were administered as per the physician's orders. * The facility failed to provide a LAL mattress as per Resident 3's care plan. These failures posed the risk for worsening of the existing pressure injuries or development of new pressure injuries for these residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control practices in accordance with the facility's P&P to help prevent the transmission of diseases and infections. * The facility failed to ensure CNA 1 wore proper PPE when entering Resident 5's room which was on transmission-based precautions. This failure posed the risk for transmission of communicable diseases to other residents in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's personal belongings were appropriately accounted for upon discharge for one of two sampled residents (Resident 1). This failure resulted in Resident 1's personal belongings not being accounted for at discharge, which had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and sanitary homelike environment as evidenced by: - The brownish stains were observed on three curtains in Shower room [ROOM NUMBER] of six shower rooms in the facility. - The shampoo dispenser was missing in Shower room [ROOM NUMBER]. - No pillowcases and washcloths were found in six of six linen closets. These failures had the potential to negatively affect the health and well-being of the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident/resident representative had participated in development of the person-centered plan of care timely for one of three sampled residents (Resident 4) as per the facility's P&P. Thisfailure put Resident 4 at risk of not receiving resident-centered care.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * The facility failed to conduct the infection surveillance for the months of November and December 2021. This posed the risk of the facility not accurately investigating and preventing new infections from developing and an outbreak going unrecognized within the facility. * The facility failed to ensure COVID 19 screening which included screening for symptoms of COVID-19 of the visitors and resident's families were completed before allowing to enter the facility. This posed the risk for COVID 19 transmission in the facility.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and homelike environment for one of 28 sampled residents (Resident 127). * The sliding door in Resident 127's room was derailed and broken, which prevented it from closing. This deficient practice had the potential to negatively impact the quality of life and increased risk for physical discomfort for Resident 127.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain an environment free from accident hazards and failed to implement the interventions to reduce the risks of accidents and injury for two of 28 final sampled residents (Residents 65 and 70). * Resident 70's smoking paraphernalia were observed at bedside. This failure had the potential to increase the risk of injury to Resident 70 and the risk of fire to the environment and other residents. * Resident 65 was assessed as high risk for fall and the intervention was to use a tab alarm (a pull-string that attaches magnetically to the alarm with garment clip to the resident) on the wheelchair. The facility failed to ensure Resident 65's wheelchair tab alarm was in good working order. This failure had the potential to result in the injury due to falls.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the oxygen tubing (device used to deliver supplemental oxygen) was dated and changed once a week as per the facility's P&P for one of 28 final sampled residents (Resident 20). This deficient practice had the potential to result in contamination of the resident's oxygen equipment and placed Resident 20 at risk for infection.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food was served at a temperature to ensure palatability for one of 28 final sampled residents (Resident 45) and three nonsampled residents (Residents 8, 69, and 103). This deficient practice had the potential to impact the residents' nutritional status and not meet the residents' desires to be served food they felt was palatable and attractive. Findings Review of the facility's P&P titled Meal Service dated 2018 showed the recommended food temperatures at delivery to the residents are as follows: [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * Multiple undated and expired foods in the kitchen. * Refrigerators A and B's temperatures were out of range. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the safe and sanitary handling of food brought from home for one of 28 final sampled residents (Resident 15). * Multiple resealable plastic bags filled with food found in Resident 15's room were unlabeled and undated. This failure had the potential for food borne illnesses.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage and refuse were properly stored. * Two garbage dumpsters were overflowing with trash, which prevented the lid from fully closing. This failure had the potential to attract pests and rodents that may carry diseases.

Inspectors wrote2. On 3/22/22 at 0800 hours, two floor tiles in Room B were observed to be cracked and chipped. On 3/22/22 at 1130 hours, a concurrent observation and interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified the finding and stated the two tiles had to be fixed. Based on observation and interview, facility document review, and facility P&P review, the facility failed to maintain a safe, comfortable, and homelike environment for the residents. * The facility failed to ensure the lint trap from the three laundry dryers were free of lint and debris. The lint traps were not cleaned every two hours to prevent the accumulation of lint and debris. This failure posed the risk for fire. * Two floor tiles in Room B were cracked and chipped. * Room C had areas of cracked dry wall and peeling paint. [...]